In health care, consumer satisfaction is an important evaluation
instrument to determine the quality of services. In recent years, the
concept has assumed much greater significance particularly in market
based health systems. Also, in World Health Organisation's
framework for health care assessment, the customer satisfaction is given
due consideration. On the contrary, in developing countries
particularly, the concept is one of the most ignored elements in
evaluation of health care systems. Pakistan is also a case in point.
Review of literature and general health management systems in the
country suggests scarcity of information on consumer satisfaction as
well as its neglect as a crucial element in health systems. This present
study--which is cross-sectional--is designed on the ground that there is
a need to incorporate consumer satisfaction in health care evaluation.
This study, presents a scientific analysis of Punjab Employees Social
Security Institution Hospital, Rawalpindi (PESSI) using the Patient
Survey Questionnaire technique, the most universal approach used by
international studies to evaluate consumer satisfaction with health
services. Based on study results, generally, we conclude that consumers
have expressed high level of satisfaction for various quality assessment
scales. Despite these findings, it has also been noted that significant
proportion of patients have also expressed medium as well as low
satisfaction for certain scales. It tends to suggest that quality of
services needs to be improved for specific items as well as certain
scales including communication, general satisfaction, and interpersonal
aspects for improvements in provision of certain services at the
hospital.

JEL classification: I11, I18, I38

Keywords: Customer Satisfaction, Quality, Healthcare, Evaluation

1. INTRODUCTION

Over the years, quality of services has assumed far greater
importance in health systems of both developed and developing countries.
In WHO's framework for health system performance assessment;
health, responsiveness and fairness of financing are three major goals
of a health system [Murray and Frenk (1999)]. With each component having
particular importance, the responsiveness element entails safeguarding
the rights of patients to adequate and timely care. (1)

With numerous assessment measures, consumer satisfaction--which
overlaps responsiveness in various dimensions--is one important
evaluation measure of quality and performance of any heath system. (2)
Similarly, 'legitimate' expectations about service quality
also serve as key tool in understanding patients' aspirations and
needs for better health care. (3) The evaluation of services vis-a-vis
consumer satisfaction is, therefore, a dynamic rather than a static
process. It provides time continuous information regarding relative
improvements (of shortfalls) in health care standards. (4)

Generally, in the case of developing countries, it has been noted
that patient satisfaction is not given much importance. It is a self
explanatory fact that formal evaluation mechanisms including consumer
satisfaction are absent in the health systems of most developing
countries. It has been argued that consumer perceptions on health care
are largely ignored by health care providers in low income countries
[Yildiz (2004)]. Moreover, it is also noted that health being the
exclusive industry--unlike others--which ignores its clients. The
prehistoric mindset of doctors that only they understand what should be
done ignore patients' inputs, which is not living in reality [White
(1999)]. Generally, these arguments appear to hold ground in countries
such as Pakistan where patient satisfaction is the ignored element in
improving health care quality and HMIS. (5) It is argued that absence of
accredited standards, lack of health care evaluation, and insensitive
attitude of management towards patients' needs are few of the
factors responsible for low quality of health care in both public and
private sectors. (6)

In macro context, low public sector spending on health is also
cited as a significant factor for deteriorating quality of health care
in Pakistan. With critical social and economic issues including
burgeoning population, low nutrition levels, increasing incidence of
poverty and disease, widening of income disparities, inflationary
pressures, and increasing health costs; government spending on health is
miniscule. According to the Economic Survey of Pakistan, in 2005-06, the
government spent merely 0.75 percent of GDP on the health sector
[Economic Survey of Pakistan (2005)]. Therefore, public expenditure on
health is abysmally low estimated at $ 4 per capita [ADB Report (2005)].
Therefore, limited accessibility (equity) and deteriorating standards of
health care (efficiency) are key issues for health regime in the
country.

With ineffectuality of public sector in health care provision; over
the years, private referral and medical treatment has become an
increasing phenomenon. Based on 2005 figures, private spending on health
(including household expenditures) is estimated at $ 14 per
capita--almost four times more than public health expenditure per capita
[ADB Report (2005)]. Akram and Khan (2007) have noted that relatively
higher income groups in urban centres despite access to public hospitals
and tertiary medical institutions prefer to consult and receive
treatment in private hospitals, which are considered as more quality
oriented [Akram and Fahim Jehangir (2007)]. Generally, in absence of
accreditation of health establishments in Pakistan, studies have noted
that for- profit establishments also compromise on quality standards
[Shaikh and Rabbani (2004)].

Poor provision of health care services, relevant health indicators
unambiguously demonstrate a trend towards increasing impoverishment and
vulnerability of the populace. Tightening of fiscal space and limited
budget allocations, and underutilisation of public sector development
expenditures; 'health for all' appears a distant reality in
Pakistan. Therefore, the concept of social protection of health--through
risk pooling-- appears to have assumed critical importance. The
mechanism not only can serve as an important policy instrument to
prevent vulnerable households from falling into 'health
poverty' but it can also provide them access to health services.

Social protection schemes--with health component--for poor,
indigent, and lower income groups exist in Pakistan. However, their
efficacy in terms of scope, service delivery, and quality requires
comprehensive evaluation. Among others, it presents a strong case to
examine the quality of health services provided under these schemes. (7)
This present study is designed with the objective to evaluate quality of
health services from consumer perspective at Punjab Employees Social
Security Institution's hospital in Rawalpindi.

2. REVIEW OF LITERATURE

2.1. Patient as Consumer

The importance of 'patient' perceptions, also referred as
consumer, in health care systems from the fact that consumer assessment
not only identifies pitfalls in quality but their expectations also
provides a way forward to improve the existent status of a health care
services [Owens and Batchelor (1996)]. (8) Usually in market-based
health systems, among various factors, patients' satisfaction is
considered as an important indicator which enhances the reputation of
hospitals and medical establishments in health provision. Therefore, it
is argued in the literature that traditional term 'patient'
needs to be replaced with customer of client for service improvements
and also to develop a respectful relationship. It has been stated that
term 'consumer' dignifies professional-patient relationship
whereas the traditional term represents powerlessness against the
medical establishment [Sitzia and Wood (1997)]. In addition, reinventing
the term strengthens the importance of patient, consumer rights, and
protection.

2.2. Consumer Perceptions: Influences and Variations

With complex nature of human perceptions, patient satisfaction is
rather a complex phenomenon. Consumer perceptions represent a diverse
mixture of perceived needs, expectations, and experience of health care
[Smith (1992)]. They seem to be influenced by various and often diverse
factors. For instance socio-demographic factors, economic status,
gender, and culture have been found to be significant in influencing
perceptions. It is stated: 'The clients' perspective is not
simply a matter of individual preferences but is mediated through the
social and cultural environment [AbouZahr, et al. (1996)]. Therefore,
with influence of multiple factors, patients' perceptions have the
tendency to vary drastically across individuals, hospitals, regions, of
countries.

In literature, perceptions on satisfaction have been identified as
relative judgements, based on comparison of perceived performance and
patient aspiration, a proposition referred as the 'multiple
discrepancy' theory [Michalos (2003)]. It is noted that
patient's aspirations can be unrealistic in view of available
financial and nonfinancial resources and performance evaluation can
differ significantly. Therefore, it is argued that legitimate rather
than individual expectations needs to be accounted for which could
assist in reducing measurement discrepancies in patient satisfaction
[Carr-Hill (1992)].

2.3. Dimensions of Quality in Consumer Satisfaction

Interestingly, patient satisfaction with quality cannot be examined
unless the multidimensionality of quality should be taken into context.
It not only entails the technical aspects of health care but also
involve non-technical dimensions including physical environment, access
to information, courtesy of medical professionals, interpersonal
relationships, responsive behaviour, time cost involved, and other
miscellaneous aspects. In health care literature, 'structural
quality' is defined as dimensions related to continuity of care,
costs, accommodation and accessibility. Process quality has been defined
to include aspects of courtesy, information, autonomy and competence
[Van, et al. (1998)]. Similarly, service quality is referred as a set of
aspects which include communication, sign posting, information provision
and staff interaction with patients [Kenagy, et al. (1999)].
Interpersonal aspects of quality, amenities of care, with technical
aspects comprise the three components of health care quality [Donabedian
(1980)]. Interpersonal aspect is defined as the quality of interaction
between the patient and the service provider concerning responsiveness,
friendliness, and attentiveness [Haas (1994)]. In the literature,
various studies therefore have examined quality specific contexts and
dimensions.

2.4. Socio-demographic Factors Influencing Consumer Satisfaction

Most studies examining relationship of patient characteristics with
hospital satisfaction scores have found certain variables to be
significantly related. Most prominently, patient age along with
self-reported health status are been noted to be statistically
significant. It has been examined in almost every study that these two
factors are strongly correlated with hospital satisfaction [Rosenheck,
et al. (1997) and Young, et al. (2000)], whether these variables have
been analysed for obstetrical patients [Finkelstein, et al. (1998)], for
various patient satisfaction measures [Marshall, et al. (1996)], and
across different countries [Thi (2002)]. Moreover, it has also been
noted that there is greater tendency of research studies to concentrate
on older patients. It seems to be based on the presumption that old
people are the major recipients of health care services. Generally, it
has been found that older patients have the tendency to report greater
satisfaction while sicker patients tend to be less satisfied
[Finkelstein, et al. (1998); Young (2000); Rosenheck, et al. (1997)].
Other patient characteristics that have been noted to be significantly
related to patient satisfaction include race/ethnicity, gender,
education, insurance status, income, and past consumer experience in the
hospital [Finkelstein, et al. (1998); Rosenheck, et al. (1997);
Hargraves (2001)].

2.5. Measurement of Consumer Satisfaction

Similar to multidimensional nature of quality, its measurement
through patient satisfaction also has varied approaches. One factor
which account for variation in patient perceptions of hospital care is
differences in measures of satisfaction [Barr and Banks (2002)]. Certain
measures focus on 'experience of care' while examining
problem- oriented approach scrutinising questions concerning what did or
did not happen while receiving health care regarding numerous aspects of
care [Cleary, et al. (1991)]. Other patient satisfaction measures take
into account the 'satisfaction with care' approach which
involves patients to rate satisfaction with various aspects of care they
received [Finkelstein, et al. (1998); Marshall, et al. (1996)]. These
two approaches to assess patients' views on hospital experiences
reflect two complementary but often conflicting goals for developing
information i.e. quality improvement by hospitals and public reporting
for use by consumers [Barr and Banks (2002)]. To assist hospitals in
quality improvement measures, specific questions identifying problem
areas needs to be used [Cleary, et al. (1991)].

2.6. PSQ--Global Approach in Measuring Consumer Satisfaction

In developed countries, interest in measuring patient satisfaction
assumed more importance during the mid 1980s, the first health
questionnaire was developed almost forty years ago [Engs (1970)]. Some
thirty years back Ware, et al. (1986) developed a multifaceted and
universally applicable approach to measure patient satisfaction through
Patient Satisfaction Questionnaire (PSQ) [Ware, et al. (1976)]. The goal
was to develop a short, self-administered satisfaction survey having
application to general population studies yielding reliable and valid
measures. These measures should have both theoretical and practical
significance for planning, administration, and evaluation of health
service programmes [Ware, et al. (1986)]. Importantly, the salient
feature of PSQ approach is its development of taxonomy of
characteristics of health care providers and services which can
influence patients' attitudes towards satisfaction with medical
care. Since its development, the modified PSQ method has been
extensively used by studies to evaluate health care services in specific
contexts in various countries. Its validity has been supported by
empirical findings since its development [Ware, et al. (1986)]. (9)

2.7. Scarcity of Consumer Satisfaction Literature in Pakistan

With bulk of international literature on customer satisfaction in
health care, it appears to be highly scarce in context of Pakistan.
Except for handful project studies conducted by NGOs and few research
articles, health care literature on patient satisfaction is grossly
lacking. With general absence of information on the subject, we find no
evidence on any research conducted on customer satisfaction with health
care services, in particular, of health schemes under social protection
mechanisms. Therefore, this neglected area provides a broad scope to
review health care services not only in terms of customer satisfaction
but also coverage and structure of delivery mechanisms. In context of
Pakistan, it seems pertinent for both policy analysis and health
protection reforms in delivering better health services to citizens of
the country.

3. REVIEW OF HEALTH PROTECTION IN PAKISTAN

Before examining the quality of services provided at PESSI
hospital, this section briefly reviews the health protection of
individuals covered under the various social security schemes in
Pakistan. As mentioned earlier, accessibility of health services and
health protection of poor, indigent, and vulnerable individuals is the
source of social concern in the country; therefore, this section
succinctly examines such schemes in particular.

In developing countries; social protection of poor, indigent, and
lower income groups is an important policy instrument. In the midst of
various protection programmes, health protection of households carries
immense significance. Generally, evidence suggests that there is a
strong relationship between poverty and health. In particular, poor
people have higher probability of having health issues. Conversely, poor
health can aggravate household poverty or even bankrupt families through
health incidents/ accidents of catastrophic dimensions. In Pakistan,
evidence seems to suggest that high prevalence of disease among poor is
the major factor pushing people into poverty [Mahmood and Ali (2003)].

In case of serious health contingencies, it has been noted that
when poor households are not health protected, they have the tendency to
borrow of reallocate expenditures towards health care from other
important consumption items such as food. This also adversely impacts
the health status through low nutrition levels.

With no significant 'trickle down' impact of economic
growth coupled with low public sector spending on health, financial
costs of health care services has been shifting to households in
Pakistan. Therefore, it appears indispensable to devise a broad based
social health protection mechanism in the country.

4. RATIONALE OF THE STUDY

The rationale for conducting this study is based by taking into
context the following considerations:

(i) Literature on patient perceptions to evaluate the quality of
health care is scarce in Pakistan.

(ii) There is no previous study which has examined quality
dimensions of health risk-pooling model in Pakistan. Therefore, quality
evaluation of Provincial Employees Social Security Institution (PESSI)
hospital vis-a-vis patient satisfaction provides this research
opportunity.

(iii) Based on review of existing literature, we find no evidence
that PSQ technique has been used by any research study in Pakistan.

(iv) Assessment of the quality dimension of health risk financing
will hopefully guide in formulating recommendations about improving the
system of health care delivery.

5. AIM AND OBJECTIVES OF THE STUDY

The primary aim of the study is suggest improvements in health care
services at PESSI hospital.

This cross-sectional study is designed on the basis of PSQ approach
[Ware, et al. 1976)]. It represents a relatively shorter version of the
approach comprising 40 questions.

These are related to different aspects of health care services
provided at the PESSI hospital, Rawalpindi.

On the basis of these questions (of items), seven broad scales have
been constructed representing key dimensions of services provided by the
hospital. These broad scales are: (i) general satisfaction (ii)
technical quality (iii) interpersonal aspects (iv) communication (v)
financial aspects (vi) time spent with the doctor, and (vii) access and
availability aspects. In each scale, consumer responses on items have
been captured through five relative scores (Likert scales) which
represent consumers' relative judgements on quality of health care
service received at the hospital (see Table 1 below).

The pre-coded responses were recoded to attain higher item scores
for favourably worded items i.e., indicating greater satisfaction in
numeric values. For example, numeric value of 'strongly
agreed' in the questionnaire was recoded from 1 to 5, and numeric
value of 'agreed' in the questionnaire was recoded from 2 to
4. Likewise, similar procedure of recoding was adopted for the remaining
three Likert scales.

After attaining relative numeric values of satisfaction for each
item and doing their recoding, the number of items under each of the 7
quality measurement scales were summed up to attain aggregate score for
each scale. For instance, the quality scale of general satisfaction
comprising eight items (i.e., PSQ1, PSQ2, PSQ3, PSQ4, PSQ5, PSQ6, PSQ7,
and PSQ8) were added up to receive the total grand score of general
satisfaction.

In consumer satisfaction studies, categorisation of numeric values
of scales measuring quality has been extensively used in various studies
for relative analysis of satisfaction. For instance, [see
Theodosopoulou, et al. (2007)]. To facilitate comparative analysis of
consumer perceptions, aggregate scale scores have been classified into
three broad categories which are: (i) High level of satisfaction, (ii)
Medium level of satisfaction, and (iii) Low level of satisfaction.
Distinction between these categories (or satisfaction ranges), for
instance in low satisfaction, is calculated by taking average point of
minimum cumulated value of dissatisfaction score and minimum cumulated
value of neither agree nor disagree scale. For example, in general
satisfaction scale, the minimum cumulative score of dissatisfaction is
16 whereas the minimum cumulative score of uncertainly is twenty four.
(10) Therefore, the average point is estimated as 20. All summated
values which are [less than or equal to] 20 represent low satisfaction
ranking.

On a similar note, the minimum cumulative point of neither agree
nor disagree and minimum cumulative point of satisfaction have been
averaged to estimate the point that differentiates between medium and
high satisfaction levels (or ranges). For example, under this method, 28
being the average point, all summated values > than 28 represent
relatively higher levels of satisfaction whereas scores [less than or
equal to] 28, but > than 20 represent medium levels of satisfaction
(see Table 2). Similar technique is applied for categorisation of
consumer satisfaction levels for other scales.

6.2. Sample Selection and Size

At PESSI hospital, Rawalpindi; around 37,000 workers are registered
under the health protection scheme. In addition, approximately 200,000
dependents (of registered workers) are recipients of health services at
the hospital. Based on hospital estimates, on average, 400 customers
visit the premises each day. Broadly, there are two types of patients:
(i) OPD patients, and (iii) Inpatients. As an inclusion criterion, the
survey exclusively involves interviews with the first type of patients.
Inpatient perceptions of care, therefore, are not under the purview of
the study.

In addition, respondents with minimum age of 18 years (i.e. adults)
were selected for the study sample. It is based on the presumption that
children possess little comprehension about complex medical procedures
and quality of hospital services. The purpose of excluding children from
the survey, therefore, was to increase the response rate. The sample,
however, makes no distinction on the basis of registration status of
respondents i.e. whether if they are employed workers (registered with
PESSI) of dependents of registered workers.

Of total OPD patients who represent the sampling frame, following
formula has been used to select sample size.

Data collection was done by a structured questionnaire comprised of
forty questions (of items) related to different aspects of hospital
services. As mentioned previously, the questionnaire was designed using
PSQ-III as a reference point. A pilot survey of ten respondents was
conducted before carrying out the complete hospital survey. To overcome
difficulties in identifying OPD patients from the consumer list,
respondents were identified through 'random selection' process
on days when data was collected. Since consumers were interviewed in
hospital's premises, the data collection procedure was
time-efficient and convenient while keeping all the survey requirements
of the study.

6.4. Data Reliability

In psychometric studies, estimation of data reliability is a
requisite procedure. In literature on perception studies (including
consumer satisfaction), it is indicated that multi-item scales generally
meet the reliability criteria when exceeds the 0.50 value for group
comparisons. (12) Among various techniques, we have estimated Cronbach
[alpha], the most frequently used in international studies. Item
reliability is estimated at 0.80 whereas scales reliability comes to be
0.74.

6.5. Ethical Considerations in Data Collection

During data collection, all methodological and ethical
considerations were taken care of. Before each interview, patient was
informed about the purpose and objectives of the study. The anticipated
participants were also informed about keeping strict confidentiality of
data that will be provided by them. Therefore, after receiving personal
consent, the data was collected from each survey participant. It was
also strictly made sure that interview process is carried out in privacy
not affected by presence of hospital staff, management, or any other
interference. After execution of the survey, patient data was entered in
SPSS 15 and before conducting analysis, it was thoroughly cleaned for
errors.

6.6. Limitations of the Study

Despite the fact that the present study is a benchmark on
estimating patient satisfaction at the PESSI hospital, it has certain
limitations. These are as following:

* It exclusively examines the perceptions of patients to evaluate
the quality of health services at the hospital. It has not incorporated
the views of the medical staff.

* It is a particular case study of patient satisfaction at the
PESSI hospital, Rawalpindi. Its findings, therefore, cannot be
generalised to other PESSI hospitals in Pakistan.

* It exclusively takes into account perceptions provided by OPD
patients at the hospital. The findings do not apply to perceptions of
inpatients who are admitted at the hospital.

7. RESULTS

7.1. Socio-economic Characteristics of Study Sample

Table 3 given below presents descriptive statistics of the sample.
In the study sample (N = 116), 56 percent of respondents were males
whereas 44 percent were females. In sub-sample of males, 92 percent were
employed workers (registered) with a miniscule share of male dependents
(8 percent). On the other hand, in sub-sample of females, only 9 percent
of respondents were employed workers (registered) while majority 91
percent includes dependents. The average age of respondents is estimated
to be 37 years. By age classification of sample, concentration of
respondents is in the age group of 31-45 years (48.3 percent) followed
by 18-30 years (33.6 percent) and 46 and above (18 percent).

On average, education of respondents was found to be abysmally low
i.e. 6 years of schooling. According to categories, around 28 percent of
respondents were illiterate, 16 percent had receive education from Grade
I-VIII, 38 percent were matriculates (high school education), whereas 18
percent were college graduates.

In the sample, average household income per month, is estimated to
be significantly low i.e. Rs 5,938 (of $ 87.3). If this mean value is
taken as the cut-off point, it is estimated that 61 percent of
households had monthly income below the mean value whereas remaining 39
percent of households had incomes above this point. These results
clearly suggests that majority of respondents in the sample belong to
poor income strata.

The range of utilising health services, in terms of years, at the
hospital is fairly large (2-30 years). Its average value is estimated as
7 years. In terms of time duration of services availed from the hospital
by category; majority of respondents were found using health services
for < than 5 years (47 percent). It was followed by 5-9 years (28
percent), and 10 years and more (25 percent). The descriptive statistics
of socio-economic indicators are presented in Table 3 below.

Consumer satisfaction literature presents mixed response to
estimating either single item responses or multiple-item scales of
satisfaction with services. For analysing psychological attributes of
consumer perceptions, potential weakness of using single item approach
has been discussed. It is argued that this approach can result in random
measurement error as individual item lack scope. Therefore, it is very
unlikely that an item can fully represent a complex theoretical concept.
Hence, summated scores have been perceived as better indices to apply in
studies pertaining to consumer perceptions on satisfaction. On the
contrary, studies on consumer satisfaction have also adopted single item
analysis with meaningful significance in inferential statistics.

With benefits of each approach in interpreting data, we have
examined individual item statistics as well as summated scales of
quality to evaluate hospital services.

7.2 (a) Descriptive Statistics of Scale Items

(i) General Satisfaction

The GS scale primarily entails physical environment of the
hospital. It includes items related to consumers' level of comfort
in diverse hospital premises. In terms of consumer satisfaction,
cleanliness and airy waiting area was highly ranked (mean = 4.06). It is
closely followed by cleanliness of doctor's room and moderately
maintained temperature of waiting area (mean values of 4.03). Comfort of
laboratory rooms was also found to be skewed towards relatively higher
satisfaction (mean= 4.0). Relatively, ease in getting the seat (mean=
3.26) and spacious sitting area (mean= 3.17) were found to have lower
satisfaction ranking compared to above items. These values tend to
suggest that despite cleanliness in hospital waiting area for consumers,
there is some evidence of physical congestion signified by bulk of
patients who wait in the area before referral. The congestion can also
be explained not only in terms of load of consumers waiting for referral
but partly also due to number of caregivers (or attendants) which
accompany them. However, overall OPD satisfaction as well as medical
care satisfaction was ranked higher by consumers (see Table 4).

(ii) Technical Quality

Consumers evaluated highest satisfaction with efficacy of medicine
under the technical quality scale (mean= 4.07). Simply, this suggests
that majority of patients were satisfied with the doctor prescriptions
of drugs at the hospital. It was followed by satisfaction with efficient
laboratory examination (mean= 3.89), and careful examination by the
hospital doctor (mean= 3.65). Compared to other dimensions, monitoring
weight of under 5 years old children (mean= 3.14) was also found to be
relatively low in terms of consumer satisfaction.

(iii) Interpersonal Aspects

The IP scale mainly takes into account consumer relationship with
hospital staff. It includes aspects such as general courteous behaviour,
caring attitude, and personal respect for the consumer while he/she is
in diverse situations while receiving health care. In the midst of
various scale items, courteous nature of reception staff received the
highest rank from consumers (mean= 4.19). It was proceeded by high
consumer satisfaction with doctors treating patients with respect (mean=
4.0), doctors respect for patients' privacy (mean= 3.79), and
courteous attitude of laboratory staff (mean= 3.73).

Contrary to above estimates, average response of consumers tends to
suggest that consumers, in general, were relatively dissatisfied with
laboratory examination (mean= 2.96). The estimate indicates that while
queuing for laboratory examination, patients are not treated on first
come first serve basis which results in wastage of time. It may also be
inferred that queuing for laboratory checks lack discipline and often
favouritism in bestowed by laboratory staff to certain consumers over
others.

Doctor's familiarity with patient history also received a low
ranking by consumers in general (mean = 2.84) in addition to their
knowledge of treatment (mean= 2.67). These estimates tend to suggest
that, although, doctors are careful in examining patients, they
generally do not refer to consumer's previous medical history and
earlier diagnosis done by another doctor. This seems to suggest that
mostly doctors prefer their own way of treatment rather than adhering to
previous medical history and diagnosis of the patient. These estimates
require further exploration of such practices from doctors'
perceptions, which is beyond the purview of this study (for details of
other statistics of IP scale, see Table 5).

(iv) Communication

In COM scale, seven out of eight items examine consumer
satisfaction while doing communication with the doctor, primarily
regarding diagnosis. Generally, the mean values of responses of items
indicate mixed satisfaction. Use of complicated medical terminologies by
doctors not understandable to the patient received highest
dissatisfaction

from the patients (mean = 4.16). (13) It can be partly explained
that since most of the consumers in the sample are lowly educated,
therefore, it seems difficult for them to comprehend simple or more
sophisticated medical terms used by doctors. It was also noted that
doctors explanation to consumers about dosage of medicine was given a
relatively moderate ranking (mean = 3.06), it appears that doctors do
not bother much if the patient has understood the dosage. It received a
very low satisfaction score (mean = 1.47). These descriptive seem to
suggest existence of communication gap between doctor and consumer
partly explained by low education of consumers and may be doctors'
reluctance to explain these aspects in detail. In addition, most of the
patients indicated that they do not receive any published material from
the doctor pertaining to their disease of issues of general healthcare
(mean = 1.24). Conversely, doctors giving further medical appointment
(mean = 3.86), and doctors' willingness to listen to patient's
health issues (mean = 3.73) received relatively high consumer
satisfaction ranking.

(v) Financial Aspect

An important estimate that has come out of descriptive analysis is
the satisfaction of patients with financial health protection at the
hospital. With average value of 4.78, it is apparent that most consumers
are very highly satisfied with the financial aspect. In proportional
terms, a staggering 97 percent of consumers indicated high level of
satisfaction with financial protection they receive from PESSI. A
miniscule 3 percent consumers mentioning dissatisfaction with the
financial aspect of health care service provided by PESSI.

(vi) Time Spent

Similar to relatively high satisfaction with willingness of doctor
to listen to patient, time spent with doctor was ranked relatively
higher by consumers (mean = 3.66).

(vii) Access and Availability

The descriptive statistics of AA are presented in Table 7. The
scale is a representative of mixture items concerning access and
availability aspects. It represents physical accessibility to the
hospital, facilities, and miscellaneous services provided at the
hospital. Interestingly, availability of medicines from hospital's
pharmacy received a high satisfaction ranking by consumers (mean =
4.23). It is followed by accessibility to radiography and laboratory
facilities (mean = 4.16), and having appointments for these medical
facilities (mean = 4.14). In addition, outside signage to assist
patients and caregivers about health care departments and other hospital
premises was also found to be highly helpful by consumers (mean = 3.88).
It is noted that consumers have to spent significant time before having
access to referral (mean = 2.80). Based on earlier argument, it also
partly indicates burden of patients visiting the hospital on a daily
basis. Moreover, accessibility to clean toilets and availability of
clean drinking water at the hospital were other key concerns of
consumers at the hospital (mean values of 1.91). It tends to indicate
cleanliness and hygiene in washrooms is one of the major issues of the
hospital along with inaccessibility of clean drinking water. It may be
inferred that partly cleanliness in toilets are not maintained by the
janitors and might be due to excessive burden of individuals using these
facilities.

Physical accessibility to hospital (in terms of distance covered)
also received low satisfaction ranking by consumers (mean = 2.5). The
estimate suggests that hospital for most consumers is not in close
vicinity of their residences. Therefore majority of patients have to
travel considerable distances to avail health facilities. Since the
hospital is the only medical establishment in the region which covers a
large circumference of rural as well as urban areas, congestion of
consumers at the hospital may also be explained by it being the lone
facility in the area.

The study has examined socio-economic factors such as gender,
education, age groups, income, and registration status of respondents
i.e. registered worker or dependent affects on measuring comparative
perceptions.

Gender

As indicated earlier, financial aspect (comprised of one item) is
the most highly ranked aspect. In overall sample, a staggering
proportion of patients indicated high levels of satisfaction with health
protection at PESSI (around 97 percent). With no statistical significant
variation across gender (P> 0.05), female consumers expressed
relatively complete satisfaction with the scale compared to 94 percent
of male consumers. In total, more than three-fourths of patients
indicated high satisfaction with 'time spent with doctor'.
Female patients expressed high satisfaction with the scale (84.3
percent) compared to males (70.8 percent). This difference is not found
statistically significant with greater variation by gender (P> 0.05).
However, interestingly, a noticeable proportion of consumers (more than
one fifth) in overall sample expressed dissatisfaction with the scale,
which is mainly influenced by male consumers ranking of the scale (26.2
percent).

In total, general satisfaction scale also represents high level of
satisfaction (66.4 percent of consumers) whereas a noticeable one-third
of patients also ranked it in medium level of satisfaction. No
significant variation in perceptions was found by gender i.e. chi square
is P = 0.197. Overall, most patients ranked communication scale in terms
of medium satisfaction (62.1 percent). Male consumers appear more
satisfied than females in communication, which represent a noticeable
share of low satisfaction (35.3 percent) with P = 0.663. More than
three-tenths of consumers also ranked low satisfaction level with
communication scale which is mainly influenced by female estimates.
Mixed responses were noted in interpersonal aspects with almost equally
proportionate responses in medium to high levels of patient
satisfaction. Female consumers were found to be relatively less
satisfied compared to male consumers. Conversely, under technical
quality, female consumers expressed high satisfaction than males (68.6
and 58.5 percent respectively) whereas noticeable share of medium
satisfaction was also estimated across females and males (29.4 and 33.8
percent respectively). All differences by gender were statistically not
significant in technical quality. Access and availability was ranked
medium level in quality with no statistical significant variation by
gender P = 0.131. For detailed statistics, see Table 9 below.

Education

Consumer satisfaction ranking with respect to education are given
in Table 10. Excluding financial aspect, ranked consistently high with
no significant variation by education P = 0.148, technical quality was
the highest ranked scale of satisfaction across education followed by
medium ranking. There was significant variation in perceptions in
technical quality having no statistical significance by education having
P = 0.167. High ranking of technical quality is estimated to be
inversely related to successive years of education till high school
educated consumers. Generally, GS scale mostly represents high consumer
satisfaction (with greater proportion of respondents) across education
whereas noticeable share of patients across all education groups also
noted as ranking the scale with low levels of satisfaction. The lower
rankings are mainly influenced by college and literate categories. In
our data, high satisfaction with Interpersonal aspects shows a
consistent inverse relationship with each successive increase of
education group. It declines from 60.6 percent to 40 percent between
college educated consumers and illiterates. However, no statistically
significant variation was estimated in responses by education.

Across education, communication scale was primarily ranked in
medium satisfaction category; however, it also represents highest
proportion of consumers who expressed dissatisfaction with the scale
(low ranking). College educated consumers expressed highest proportion
of dissatisfaction compared to other education groups.

The interesting finding is that, excluding access and availability
scale, illiterate consumers expressed high levels of satisfaction with
all scales compared to other education groups. These comparative
estimates tend to suggest that consumers with no education have low
aspirations; little comprehension about quality of services due to
confined exposure to other health facilities, and resultantly has high
satisfaction levels.

Age Groups

Almost every study has estimated significance of patient age along
with self- reported health status. In particular, older patients have
drawn more research interest in consumer perceptions. It seems to be
based on the proposition that older populations (usually > 60 years)
are the most frequent recipient of health care services. It has also
been noted as a consistent finding that older patients tend to be more
satisfied with their health care [Thiedke (2007)]. The study estimates
appear to confirm these findings. (14)

As the statistics indicate, almost across all scales (excluding
communication), consumers with ages of 46 years and above, ranked high
satisfaction compared to other age categories. Under general
satisfaction, 90.5 percent of older consumers expressed satisfaction
with health care services followed by 18-30 years age group (69
percent). Likewise, with technical quality, 71 percent of older
consumers expressed high levels of satisfaction, which is estimated as a
consistent decline across younger consumer groups. In interpersonal
aspects, a significant proportion of consumers across all age groups
expressed medium levels of satisfaction whereas in communication scale,
a noticeable proportion of consumers expressed dissatisfaction with
services provided under the scale. This was found consistent across all
age groups. Similar to interpersonal aspects, access and availability
was predominantly ranked in medium satisfaction category across age
groups.

Household Income

As mentioned earlier, industrial workers earning up to Rs 5,000 per
month (and their dependents) are eligible for registration and medical
benefits at PESSI hospitals over all Pakistan. For analysis of data, we
have categorised income groups on the basis of this income level. Based
on tests of significance, variation in satisfaction levels by income
groups have been estimated to be significant.

Consumers by both income categories apparently ranked technical
quality as the most highly satisfied scale. It was followed by general
satisfaction scale i.e., 72.2 percent of consumers (monthly household
income > Rs 5,000) expressed higher satisfaction compared to around
55 percent with monthly household income < Rs 5,000. However, there
is a significant proportion in both categories which also ranked GS as
medium satisfaction scale. In both categories, medium satisfaction with
access and availability, and interpersonal aspects is noted for the
scale.

Registration Status

According to estimates (Table 13), across all scales, dependents
were found to be more satisfied with services provided at the hospital.
In general satisfaction scale, 72.5 percent of dependents expressed high
level of satisfaction. Almost, 39 percent of secured workers indicated
medium level of satisfaction. Similarly, more than two-thirds of
dependents indicated high satisfaction with aspects of technical quality
(29.4 percent indicated medium satisfaction) whereas more than one
thirds of secured workers mentioned medium satisfaction. In
interpersonal and communication scales, high satisfaction with quality
of services is estimated to be relatively lower mainly concentrated in
medium satisfaction scale. Almost similar results have been estimated
for access and availability scale.

8. DISCUSSION, CONCLUSION AND RECOMMENDATION

Recent research considers consumer perceptions with health care
services as an essential part of understanding and assessing quality. In
market-based health systems, most notably in developed countries,
patient satisfaction has become an integral part in evaluating quality
of health services. It is principally based on recognition of patient as
a consumer and also payer of services has acknowledged rights and
protection. In addition, the importance of consumer satisfaction also
stems from the fact that quality perceptions are one of the important
indicators which measure the reputation of hospitals and thereby draws
more consumers if the reputation of services is high.

Many studies have explored patient's perceived satisfaction
for outpatient services from different dimensions, such as waiting
times, courtesy and interpersonal skills, professionalism and so on.
However, in Pakistan, such evaluation of services is rare in Pakistan
and particularly for PESSI hospitals, they are non-existent. In this
study, we have examined outpatient satisfaction in terms of isolated
items representing services as well as perceptions on quality of scales.
Furthermore, socio-economic characteristics of patients have been
examined in influencing ranking of quality of scales. Both methodologies
have been important in explaining the influence of multiple factors on
satisfaction. For this present study, we have only focussed on patient
perceptions about satisfaction level; however, it is felt that there is
room for further analysis in terms of understanding costumer expectation
about health services in context of socio- economic characteristics of
patients.

Regarding patients satisfaction in terms of education, it has been
observed that illiterate patients generally expressed higher
satisfaction with quality of scales compared to other education groups.
In our study we have illiterate (36.4 percent), literate (14.5 percent),
matriculate (34.5 percent) and above metric (14.5 percent) patients
showing high level of satisfaction. Further in our analysis,
satisfaction levels of females generally were found to be higher for
most scales in comparison to males. This may be due to the sub-sample of
females which predominantly comprise dependents. Being dependents in
social context of Pakistan, women have presumably limited exposure to
variety of services available in the health market. Being economically
subjugated as dependents, they also have little aspirations. It may be
inferred that, partly due to influence of these factors, women generally
tend to have higher satisfaction. Interestingly, patient satisfaction
may not necessarily mean that quality is good; it may only indicate that
expectations are low

Over all, based on evaluation of services at PESSI hospital through
customer satisfaction, it is noted that there is good evidence available
that the hospital offers certain benefits to its customers which are
usually lacking in most government sector hospitals. First and foremost
is the aspect of social health protection in terms of financial security
that has been given to registered workers and their dependents. In a
country like Pakistan where health protection is a luxury for majority
of population, risk pooling mechanism of the hospital offers
considerable fiscal relief to its recipients. Other aspects like free
availability of medicines, relatively better treatment of doctors,
generally courteous behaviour of medical staff including doctors,
accessibility of radiographic facilities, and relatively comfortable
physical environment are some other significant benefits which are
offered by the hospital.

On the other hand, it has been noted that partly due to relative
advantages of the hospital (presumably from public sector hospitals),
there is excessive influx of patients at the hospital from far off areas
on a daily basis involving high travel costs. It has been noted that
patients may prefer to travel to a more distant facility if they feel
that it provides better services, including a range of care options
[Creel, et al. (2002)]. However, there is resultant congestion and some
of the standards for certain health care items are jeopardised. For
instance, cleanliness and hygiene of certain physical premises such as
washrooms is noted as a major health issue at the hospital. Likewise,
unavailability of clean drinking water was also a source of concern for
customers. The element of hospital congestion may also be inferred in
terms of waiting time customers have to go through before consultation
with the doctor. In addition, communication scale in general has
received particularly low rating. Also, there is a need to improve the
quality of items in other scales including general satisfaction,
interpersonal skills, and access and availability aspects. In the
absence of any indigenous HMIS system, the hospital needs to focus on
improving the quality of these scales since it has been catering to
significant population of workers and their dependents.

Comments

The study is focused on evaluating the quality aspects of health
care provision using consumer satisfaction as an instrument to assess
patients' perceptions about the use of services. I appreciate the
authors' effort to address a crucial topic for evaluating health
care systems and its quality for which limited information and research
is available in Pakistan. Using Patient Satisfaction Questionnaire (PSQ)
technique measured on a five category scale ranging from 'strongly
agree to 'strongly disagree', self perceptions of individuals,
the study analyses consumer satisfaction about health care services. The
sampled population is drawn from a Social Security Hospital in
Rawalpindi, established under the social protection scheme in the Punjab
province.

After a comprehensive review of literature on dimensions of quality
in consumer satisfaction and the operating of health protection schemes
in Pakistan, the authors have tried to justify the relevance of the
study in using evaluation of its quality through patients'
satisfaction criteria. However, the paper has a number of limitations
regarding the study design, sample selection and its size, data
collection methodology and data reliability which will be discussed
briefly.

Based on the sampled population of a social security hospital in
Rawalpindi, the study has strong built-in selection bias by presenting a
case study of a small hospital. From a pool of 37,000 hospital employees
and 200,000 dependents as service users, the data has been collected
from only 120 respondents--a sample too small to be representative for a
meaningful analysis.

As for the data collection methodology, only outpatients visiting
the hospital for seeking health services during certain hours have been
interviewed about the satisfaction of services, whereas in-patients who
are admitted in the hospital and spend longer time and use multiple
services for curative and treatment process, as well as the medical
staff who provide those services, have been left out. The results thus
represent the perceptions of outpatients only leaving out the input by
the medical staff and inpatients who are equally important in giving
opinion about health service provision and its quality. Moreover, the
consumers' responses on the quality of services provided at the
hospital have been captured through five relative scores based on
personal perceptions (see Table 1 in the paper) that are hard to
quantify and explain the distance between categories of responses.

Looking at the socio-economic characteristics of the study sample
(Table 3), it is apparent that the respondents with a mean age of 37
years have largely low education level, low monthly household income,
and an average family size of 5.4 children- -factors that are all
reflective of low socioeconomic status. However, a majority of
respondents have indicated high level of satisfaction about the quality
of services. This might reflect the biased perceptions of respondents
because the hospital selected is managed by the Social Security Scheme
of the government with services offered at very low price of user
charges mainly to facilitate medical benefits to the registered
employees and its dependent families, who mostly have low socio-economic
status and hence feel satisfied with free availability of services.
Certainly, the perceptions of consumer satisfaction in private hospitals
with high costs and user charges would be different than presented here
and the results would become more meaningful if compared with a
privately managed hospital with high price charged for services.
Moreover, many other quality indicators such as patient/doctor ratio,
client inflow, type of services offered, quality of the paramedic and
technical staff, etc., would be useful additions to assess service
quality and consumer satisfaction.

In all, the study is stretched far with detailed data and
tabulations on only 120 respondents raising many questions than giving
answers about the utility of this approach to assess quality aspects of
health services, and about how to improve services at social security
institutions and making policy interventions at other health service
outlets. I suggest that some sections of the paper including literature
review, health protection and social assistance schemes could be
synthesised to present it as a conference paper.

(1) Responsiveness is a relatively newer area in health research.
It has often been defined, in the context of a system, as the outcome
that can be achieved when institutions and institutional relationships
are designed in such a manner that these are cognisant and respond
appropriately to universal expectations of individuals.

(2) In addition to evaluation of health status through morbidity
and mortality estimates, there has been equal emphasis on quality of
care indicators in health systems research [Shaikh and Rabbani (2004)].
Therefore. patient satisfaction can be used as an instrument in health
management information system which can improve the quality of services
by tracking certain dimensions of quality.

(3) Legitimate needs are defined as being universal rather than
individualistic and confirms to recognised principals or accepted rules
and standards.

(4) In developed countries, patient satisfaction surveys are
conducted in hospitals on a timely basis as a measure to monitor the
performance of health establishments.

(5) Presently, in most hospitals in Pakistan, majority of
facility-based HMIS systems only track type and quantity of services
which are related to improvement in health status indicators.

(6) The concepts of patient satisfaction, patient rights, and
protection, therefore, carry little significance in most hospitals and
medical establishments of Pakistan.

(7) For a brief review of the health component of social security
schemes in Pakistan, see Section 3.

(8) It is suggested that the patient should be defined as a
consumer, a rationale that originates from the emphasis on the market
mechanism.

(9) Shorter versions of PSQ have been designed and utilised for
conducting two national surveys in the United States and was also used
in RAND's Health Insurance Experiment [Ware, et al. (1986)].

(10) In general satisfaction scale comprising eight items, the
minimum score of strong dissatisfaction is eight.

(11) The response rate of the sample is estimated to be 97 percent.

(12) However, some studies have estimated less than 0.40
reliability values which do not infer insignificance. Such data
estimates are reliable but relatively weak at high confidence intervals.

(13) It is a negatively worded item. See methodology for negative
and positive worded items in the questionnaire.

(14) Although, in our study sample, only 12 percent of the
respondents were greater than fifty years. Only 3 percent consumers had
a minimum age of sixty years compared to international studies where
older patients comprise significant proportions.

Nasir Ayat is Consultant Health
Economist and Mahmood Khalid is Research
Economist at the Pakistan Institute of Development Economics, Islamabad,
respectively.